USF College of Nursing ~ Nursing Process Worksheet Pediatric
Student :
Mackenzie Kemp
Date: 3/20/15
Instructor Kristina Kochman
Team:
Age/Gender:
Weights/Measurements
Weight
Length
Head circumference
BMC UD
Cultural Considerations: Caucasian. n/a
Kg/cm
9.70 kg
76.00 cm
47.00 cm
Growth Chart % or Range
7.23%
0.57%
19.18%
History of Present Illness/Admitting Diagnosis:
Patient is a 20 month old male with an extensive past medical history including hypoplastic left heart syndrome status post
cardiac transplant in 2014, who presented to ACH on 3/16/15 from the infusion clinic where he was noted to have a sodium of
149 and diarrhea for 3 days. His foster mother states that he was in his usual state of health until 3/13/15 when he began to
have increased episodes of reflux, vomiting, irritability, and loose stools. He was at the cardiac clinic the morning of 3/16 to
receive IVIG but due to the mother’s reports and the patients increased sodium was admitted to the PICU for further
monitoring and management. The patient’s stool was positive for C.Diff. He is currently being treated in PICU with Flagyl,
Prevacid, and IV fluids. Hypernatremia has been corrected to 139 now, however his potassium and magnesium levels were
found to be somewhat low and he is not receiving replacement electrolytes.
Pertinent Medical History:
1. Cardiac transplant 6/24/14 due to ventricular dysfunction due to hypoplastic left heart syndrome, mitral stenosis, and
aortic stenosis.
2. Multiple heart biopsies on 7/7/14; 8/12/14; 9/17/14 to assess rejection.
3. High risk for rejection with high PRA. Under intensive immunosuppressive regimen.
4. History of right hemidiaphragm paralysis.
5. Feeding intolerance status post GJ-tube placement in 10/14.
6. Developmental delay.
7. Right coronary artery occlusion.
8. History of clostridium difficile infection.
Medication/Dose
Magnesium sulfate
250mg/2.5mL, Q6H;
2.5 ml/hr
MetroNIDAZOLE
(FLAGYL)
75mg/1.5mL, Q6H
Mycophenolate mofetil
(CELLCEPT)
300mg/1.5mL; Q12H
Aspirin 40.5mg/0.5
tab; Q/day
Indication for use
Low magnesium level
(1.4)
Dosage Range/WNL?
25 to 50mg.kg/dose
YES
Side Effects
Hypermagnesemialethargy, flushing
Treat C.Diff infection
30mg/kg/day YES
Seizures,
encephalopathy
Clinical Teaching
Call DR if flushing,
extreme drowsiness,
sweating
Take for full length of
time prescribed
Immunosuppresionheart transplant
rejection prevention
Blood clot prevention
600mg/m2/dose
2x/day YES
Nausea, Vomiting,
Diarrhea
Increases risk of
infection!
75-325 mg/day
NO, dose is lower
Upset stomach,
drowsiness, headache
Call Dr if tinnitus,
bloody stools
Assessment:
Objective findings:








Pt alert, active, moving extremities, smiling
Lungs clear
Regular heart rate and rhythm
Abdomen soft, nontender, nondistended
Afebrile
Pt resting on and off
No signs of distress, pain, irritability
No diarrhea during diaper changes during my shift (11-5)
Subjective findings:
Mother at bedside, reports no pt distress
Vital Sign
Temp
HR
RR/O2 Sat
B/P
8A
36.4
116
34
120/73
12N
36.8
128
31
122/77
Site/Source
Axillary
Left leg
Normal Ranges
36-38
80-130
25-35
95-105/56-68 HIGH
Lab/Radiology Results:
WNL?
Clostridium Diff.- PCR stool DETECTED
Sodium: 139 (135-145)
YES
Potassium: 3.2 (3.5-4.5)
NO. LOW
Problem List:
Magnesium: 1.4 (1.6-2.3)
NO. LOW
1. Risk for impaired skin integrity r/t diarrhea.
2. Fluid & electrolyte imbalance r/t excessive fluid loss a.e.b. low
WBC: 3.37 (6-14)
NO. LOW
magnesium and potassium levels.
3. Imbalanced nutrition-less than body’s requirements r/t loss of fluids through diarrhea a.e.b. inability to tolerate PO
feedings.
Priority Nursing Diagnosis: Fluid & electrolyte imbalance r/t excessive fluid loss a.e.b. low magnesium and
potassium levels.
Planning /Outcomes (Individualized, Realistic, Measurable, and By When?):
 Short Term Goals:
o Prevent the spread of C-diff by adhering to contact precautions and frequent hand hygiene during
shift.
o Client will remain free of N/V during shift.
o Client will maintain balanced intake and output during shift.

Long Term Goals:
o Electrolyte ranges will return to WNL by time of patient’s discharge.
o Patient will have no diarrhea by time of discharge.
Developmental Stage (Erikson): During the first two years of a child’s life, the child faces the crisis of trust vs. mistrust.
This stage focuses on the infant’s needs being met by the parents and the child’s consequential development of lack of trust. If
the parent exposes the infant to warmth, regularity, and affection, the infant should develop trust appropriately. If the parents
fail to provide security and do not meet the infant’s basic needs, a sense of mistrust, withdrawal, and suspicion may result. As a
20 month old, the patient seems to be completely successful in this stage. Although he has a foster mother and his previous
parental relationship is unknown, the foster mother remained at the child’s bedside for almost the entire day today and a
relationship of great mutual love and affection was witnessed. The foster mother mentioned that she had first met the patient
last February so it would appear that they have had over a year of good bonding time.The patient displayed no signs of mistrust
or withdrawal from the mother or caregivers despite his complicated health and social history.
Developmental Milestones/Delays?
The patient does have a developmental delay. At 20 months of age, the patient should be able to: say several single words,
shake head “no”, can follow one-step single commands without any gestures, and walks alone. This patient was certainly
unable to talk and walk and could not even sit up on his own without a little help. This is most likely due to the child’s
complicated medical history related to his early heart transplant and subsequent infections and hospital stays. Ofcourse, he will
continue to be monitored for development.
Family structure/support system:
The patient lives with his foster mother. They have reportedly been together since last February and appear to have a loving,
mutual relationship. Previous familial history is unknown to me.
Patient/Family Education Needs (Medical, Safety, Prevention, Community Resources,…)
 Infection prevention in immunosuppressed patients
 Frequent handwashing and contact precautions with C.Diff infection
 Medication side effects
 Monitoring developmental milestones…what should be expected